Kraemer et al Sep • Oct 2009

[ Sports Physical Therapy ]

Recovery From Injury in Sport:

Considerations in the Transition From
Medical Care to Performance Care
William Kraemer, PhD, CSCS,* Craig Denegar, PhD, PT, ATC, and Shawn Flanagan, BS, CSCS

Return from athletic injury can be a lengthy and difficult process. The injured athlete commonly receives care from several
providers during rehabilitation. As their condition improves, injured athletes resume strength and conditioning programs
and sport-specific activities in preparation for return to play. Until full medical clearance is provided to return to sport and
the athlete is psychologically ready to return to play, the injured athlete remains a patient regardless of who is developing
and supervising each component of the recovery process. An understanding of and commitment to the plan of care for each
athlete, as well as communication among health care providers, strength and conditioning specialists, coaches, and the ath-
letes, are essential to the safest and most efficient recovery from injury.
Keywords: sports injury; sports medicine; strength training

R
eturn from athletic injury can be a lengthy and diffi- closed kinetic chain squats) and sport-specific movements that
cult process. The injured athlete commonly receives makes up the complete strength training program for an athlete.
care from several providers, including physicians, ath- Both exercise templates are vital in the recovery process.2
letic trainers, physical therapists, and strength and condition- In contrast to linear improvement, rehabilitation is often a
ing specialists. At some point in the recovery process, athletes haphazard process with positives and negatives occurring
return to strength and conditioning programs and resume sport- daily. Consequently, athletes usually benefit from input from
specific activities in preparation for return to play. The transi- all providers throughout the process of returning to play.
tion is important for several reasons. First, although the athlete Unfortunately, athletes often pay the price for poorly coor-
may have recovered in medical terms (ie, improvements in flex- dinated recovery plans within the return-to-play process.4
ibility, range of motion, functional strength, pain, neuromuscu- Communication is a vital factor. A lack of communication
lar control, inflammation), preparation for competition requires between medical providers, strength and conditioning special-
the restoration of strength, power, speed, agility, and endurance ists, and team coaches can slow or prevent athletes from return-
at levels exhibited in sport. Such sport-specific training may ing to peak capability and increase the risk of new injuries
be beyond what those attending to the athlete’s medical needs and even more devastating reinjuries.5 In addition, care provid-
are qualified or prepared to provide.1 Returning from injury is ers must consider the possible psychological consequences of
a process requiring additional work from the injured athlete injuries, and they should position themselves to identify and
to regain competitive ability. Exercise must be prescribed with address or refer such issues to appropriate parties when iden-
an emphasis on the fundamental components of the exercise tified. Unfortunately, communication between clinicians is
prescription,2 which progressively incorporates activities and often suboptimal, face-to-face meetings infrequent, and clearly
skills displayed in sport.2,3 When athletes resume team-based defined roles lacking in the return-to-play process.5
strength and conditioning activities, emphasis should be on Coaching staffs and administrative personnel must work to
generic movements (exercises inherent to most sports, such as ensure that care can be provided at all points of the rehabilitation

From University of Connecticut, Storrs, Connecticut

*Address correspondence to William Kraemer, PhD, CSCS, FNSCA, FACSM, 2095 Hillside Road, Department of Kinesiolog, Unit 1110, Storrs, CT 06269-1110 (e-mail:
[email protected]).
No potential conflict of interest declared.
DOI: 10.1177/1941738109343156
© 2009 The Author(s)

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INITIAL INJURY!
Program Domains for the
PROCESS PROVIDOR ROLE Design of a Resistance
Training Program
Examine, re-evaluate, Decisions must be made
1. Physicians diagnose, surgical for each program domain
correction Order of Exercise
Choice of Exercises
Medical Treatment What is the sequence
1. Physical Therapists Manage pain, limit What exercises will be
of the exercises
2. Athletic Trainers swelling, protect injured used in the program?
chosen?
3. Physicians tissues
Intensity
Restore Motion,
1. Athletic Trainers What will be the
Neuromuscular control of
Rehabilitation 1. Physical intensity of resistance
individual muscle/muscle loading of the
Therapists
groups exercises used?

1. AthleticTrainers
2. Physical Therapists Restore balance, reflex Number of Sets Rest Period Lengths
End-stage rehabilitation 3. Strength and control, strength,
How many sets will be How much rest will be
Conditioning endurance
used for a given utilized between sets
Specialists and exercises?
exercise?

1. Strength and
Generic-specific Restore most basic physical
Conditioning
development performance functions
Specialists

1. Sports Coaches
Sports-specific 2. Strength and Restore competitive
development Conditioning performance functions
Specialists
Figure 2. Program design variables.
Figure 1. The process of care for an athlete who is
returning to play, with different providers and roles.

for a number of reasons, including the restoration of balance,

the development of reflex control, the redevelopment of neu-
romuscular control and function, and the development of
process, especially when funding dictates the need to hire
strength and endurance in injured tissues.2,10,12 During the
personnel capable of addressing injuries at multiple levels.6,7
latter stages of rehabilitation treatment, goals shift from the
Under most circumstances, individual providers should not be
resolution of impairment to functional recovery.8,11 During
expected to possess the knowledge and training needed to
this period, exercises directed toward overall fitness are initi-
ensure complete recovery for athletes through all stages of the
ated, as are more aggressive but closely supervised strength,
return-to-play process.
endurance, and neuromuscular retraining activities.2 In many
Our purpose is to address the process of transition that takes
cases, these activities occur in the weight room or in open
place once rehabilitation from injury is near completion and
spaces, outside the confines of a clinic. Acute program vari-
athletes are ready to begin strength and conditioning activities,
able prescriptions (see Figure 2) are increasingly focused
highlighting some common considerations en route to an expe-
on encouraging adaptations that will improve physical abili­
dient and successful injury recovery.
ties of high specificity to the performance demands of the
athlete’s sport.3
FROM INJURY RESOLUTION TO Care and proper progression (or periodization) are needed
PERFORMANCE RESUMPTION
with conventional heavier resistance training programs. The
The paradigm found in Figure 1 provides an overview of the injured tissues must be carefully monitored to assess tolerance
injury and recovery process. A thorough examination of the to exercise stress. Initially, recovery exercises (closed kinetic
injured athlete and a careful evaluation of all findings are chain using body weight) may be highly stressful. Although
essential to an accurate diagnosis, from a structural and biome- well intended to stimulate tissue, they can cause overload dam-
chanical perspective. A clear understanding of the injury and age and inflame previously injured or immobilized tissue. For
of the interventions from each provider is vital to an efficient example, after an initial strength improvement session, a
and successful return to play. Each provider must make clear recovering patellar tendon may be irritated, requiring thera-
the purpose of each treatment and the restrictions from peutic interventions such as rest, ice, compression, and eleva-
specific activities during the rehabilitation process while tion to mitigate symptoms and expedite the process of recovery
providing supervision at points of progression and when new so that further progressive resistance exercise sessions can take
activities are initiated. place with minimal delay.9,10 The athlete must be monitored for
Resistance training is critical to the resolution of impair- signs and symptoms of overload to the healing tendon that
ment and the recovery of function.2,10,12 Early in rehabilita- would not be of concern for a healthy athlete participating in
tion, resistance training is typically of lower intensity and the same conditioning program. Training might begin with
often supervised by a physical therapist or athletic trainer in carefully monitored unilateral exercises using open kinetic
a clinical setting or in close tandem with strength and con- chain movements, progressing to weightbearing closed kinetic
ditioning specialists. Early resistance exercise is prescribed chain movements, and finally, bilateral closed kinetic chain

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 Kraemer et al Sep • Oct 2009

movements. Such a progression would help permit the peri- In a healthy state, the tissues of the musculoskeletal system
odization of exercise stress and a central focus on the tissues respond to exercise through a process of damage and repair.2
in need of gains in force production and conditioning. If the tissues are excessively overloaded, injury can occur.
An awareness of the exercise prescription on any given day When an athlete is recovering from an injury or surgery, tis-
will better enable rehabilitation providers to anticipate, col- sue is already compromised and thus requires far more atten-
laborate, and administer treatments. Furthermore, clinicians tion despite the recovery of joint motion and strength.13,18
must inform strength and conditioning specialists on the status Moreover, injuries and surgical procedures can create detrain-
of injuries. Regardless of an athlete’s apparent level of recov- ing issues that increase the likelihood of further injury. For
ery, constant feedback from the athlete is needed to gauge and example, when the midportion of the patella tendon is har-
adjust exercise prescriptions. The athlete’s perception during vested for use in the reconstruction of the anterior cruciate lig-
periods of recovery from injury can provide valuable direction ament, the bone of the distal pole of the patella is weakened,
in the decision-making process. as is the tendon itself. Excessive loading of these tissues can
In addition, athletes must be regularly assessed to ensure result in fracture or tendon rupture during training, thus creat-
that they are not attempting to conceal worsening conditions ing an entirely new injury and process of recovery outside of
or delay return to play because of a lack of confidence or dis- what was already planned for the anterior cruciate ligament.12,15
agreement in the perceived severity of the injury. Such moni- Strength and conditioning specialists must have an awareness
toring is the responsibility of all involved until the athlete has of the risks created by some of the common operative and
been provided medical clearance to discontinue all rehabilita- rehabilitative procedures.18 For example, ankle immobilization
tive care and return to unrestricted sports participation. designed to promote healing of an injured anterior talofibular
Of critical importance is mutual agreement between all ligament could lead to significant strength loss in muscles asso-
involved parties over the athlete’s readiness to rejoin highly ciated with the immobilized ankle joint. Consequently, strength
demanding sports and conditioning activities.13 Medical providers and conditioning specialists must be sensitive to vulnerabilities
must be assured that injured tissue is capable of withstanding and weaknesses caused by injuries.
the demands of sports and that muscle and joint impairments
have been sufficiently resolved13,14; moreover, coaches must be SUMMARY
confident that the athlete is adequately conditioned and phys-
ically capable of performing at a high level. Before athletes The severity of an injury and the complexity of the medical
rejoin practice and other live competitive scenarios, coaches and surgical care affect the rate of recovery and the extent to
must believe that he or she can contribute to the success of which rehabilitation must be supervised in some cases. In all
the team. cases, clear and open communication is required from each
Injury is more than physical; that is, the athlete must be psy- person who is participating in the care process. Until full med-
chologically ready for the demands of his or her sport. Many ical clearance is provided to return to sport and the athlete
individuals assist athletes through the recovery process and is psychologically ready to return to play, the injured athlete
can foster psychological readiness, but they can also iden- remains a patient regardless of who is developing and super-
tify those who are physically recovered but require more time vising each respective component of the recovery process.
or intervention to be fully prepared to return to competition. Strength and conditioning specialists should give assess-
Thus, rehabilitation and recovery are not purely physical but ments of performance to health care providers with objec-
also psychological.16,17 tive and quantifiable information that can show reliable,
Individuals cope with illness and injury in different ways. time-based trends indicative of improvement or lack of prog-
Despite the ineffective and sometimes counterproductive cop- ress. Ultimately, successful rehabilitation depends on trust.
ing behaviors, a number of approaches may be effective in The athlete must trust that all who participate in the treat-
assisting psychological recovery.16 Beyond the physical impair- ment and rehabilitation process place the welfare of the
ments relating to sport, limitations and disabilities associ- athlete first.
ated with injury and recovery may cause additional distress.
Concerns over reinjury, regaining status on a team, and failing NATA Members: Receive 3 free CEUs each year when you subscribe to
to perform at preinjury levels are common and can affect the Sports Health and take and pass the related online quizzes! Not a subscriber?
rate of recovery through overuse, avoidance, and other compli- Not a member? The Sports Health–related quizzes are also available for
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best provide the psychological care for an athlete who is recov-
ering from injury.16 Athletes may train excessively for return to
play and quickly become the biggest threat to successful recov- REFERENCES
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nation to overtrain injured tissues. performance. Curr Sports Med Rep. 2002;1(3):165-171.

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